Put to Rest Anesthesia Misconceptions

Understand forms of anesthesia, and their guidelines, for better documentation and reporting.

By Michelle N. Myrick, CPC, CPC-I
There are many forms of anesthesia that may be used when performing (surgical) therapeutic or diagnostic procedures. Excluding office-based anesthesia, these include general anesthesia (GA), monitored anesthesia care (MAC), and regional anesthesia. Having so many options is advantageous to the provider and patient, but can be a source of consternation for the coder. A review of anesthesia procedures, and their guidelines and documentation, will help you report these services appropriately.
General Anesthesia
General anesthesia (GA) is induced with a combination of anesthetic medicines inhaled through a face mask or given intravenously to cause the patient to become unconscious. After the patient is unconscious, anesthesia may be maintained using any one, or combination, of these methods, as well as an endotracheal (ET) tube or a laryngeal mask airway (LMA) device. Under GA, the patient should be completely unaware and not feel pain.
General anesthesia affects the whole body, suppressing many of the body’s normal automatic functions:

  • Breathing;
  • Heartbeat;
  • Circulation of the blood (such as blood pressure);
  • Movements of the digestive system;
  • Throat reflexes such as swallowing, coughing, and gagging; and
  • Muscle movements.

An anesthesia specialist must keep a balance of medicines while watching these vital functions.
As the patient begins to awaken from general anesthesia, he or she may experience some confusion, disorientation, or difficulty thinking clearly. This is normal, and after some time the effects of the anesthesia wear off.
Monitored Anesthesia Care
It’s important to distinguish between “monitored anesthesia care” and “sedation/analgesia.” In October 2004, the American Society of Anesthesiologists (ASA) House of Delegates approved a statement entitled “Distinguishing Monitored Anesthesia Care from Moderate Sedation/Analgesia” (www.asahq.org). Monitored anesthesia care (MAC) implies the potential for a deeper level of sedation than that provided by sedation/analgesia, and is always administered by an anesthesiology provider. MAC standards for preoperative evaluation, intraoperative monitoring, and the continuous presence of the anesthesia care team, are no different from those of general or regional anesthesia (see: ASA’s “Position on Monitored Anesthesia Care” www.asahq.org, 2005).
A variety of medicines are commonly administered during MAC, with the intent to provide patient comfort, maintain cardiorespiratory stability, improve surgical conditions, and prevent recall of unpleasant perioperative events (amnesiac quality). MAC is an attractive method of anesthetic because, conceptually, it invokes less physiologic disturbance and allows for a more rapid recovery than general anesthesia. MAC may include varying levels of sedation, analgesia, and anxiolytics as necessary for the individual patient.
The MAC provider must be prepared and qualified to convert to general anesthesia, when necessary. The conversion to GA is determined by the patient’s level of consciousness, not the use of airway instrumentation.
Regional (Spinal and Epidural) Anesthesia
Aside from reducing potential “stress response” to surgery and reducing the incidence of post-surgical complications, spinal and epidural techniques can be used to extend analgesia into the postoperative period. This form of postoperative pain management has been shown to provide better analgesia than parenteral opioids.
The differences between spinal and epidural anesthesia are:

Epidural Spinal
Injection is made into the area just outside the sack of fluid around the spinal cord. This is the epidural space. Injection is made into the fluid in the spinal cord (CSF or cerebral spinal fluid).
Takes effect in about 10-20 minutes Takes effect right away
Used for longer procedures Used for shorter, simpler procedures
A small tube (catheter) is often left in place. This can be used to deliver more medicine to help control pain during or after the procedure. Usually only injected once so there will not be a catheter in place. When a continuous spinal is possible, however, a catheter would be put into place.
Often used during labor and delivery, and for surgery in the pelvis and legs Often used for genital, urinary tract, or lower body procedures

These methods of anesthesia are meant to numb or block feeling in a certain part of the body, only.
Epidural and spinal anesthesia are often used when:

  • The procedure or child labor is too painful without any pain medicine
  • The procedure is in the abdomen, legs, or feet
  • The body can remain in a comfortable position during the procedure
  • Fewer side effects and a shorter recovery is desired
  • Oxygen levels in the blood, the pulse, and blood pressure are checked during the procedure.

Documentation: Pre-op 
Anesthesia is a continuous service that includes three major components: Pre-anesthesia (pre-op), intraoperative/procedural anesthesia, and post-anesthesia (post-op).
Per the Centers for Medicare & Medicaid Services’ (CMS) Interpretive Guidelines, Section 482.52(b)(1), all patients who receive general, regional, or MAC must have a pre-anesthesia evaluation performed. Although portions of a pre-op evaluation may be performed as long as 30 days before surgery, specific elements must be completed and documented within 48 hours immediately preceding the induction of anesthesia. The moment medication is administered for, or in preparation of, anesthesia marks the end of the 48 hours, by which time a review of the medical, anesthesia, and drug/allergy history, as well as an interview (if possible) with the patient and a physical exam of (at minimum) the cardiovascular and respiratory systems must be competed and documented.
The pre-anesthesia evaluation may only be performed by someone qualified to administer anesthesia. This includes certified registered nurse anesthetists (CRNA) or anesthesiologist assistants (AA) under the supervision of a qualified anesthesiologist or medical doctor/doctor of osteopathy who is immediately available, if needed. (The CRNA may be exempt from supervision, depending on state regulations.)
Standards of anesthesia care require documentation of the following elements, which may be documented outside the previously discussed 48-hour timeframe but cannot be more than 30 days before the induction of anesthesia (and must be reviewed and updated as necessary within the 48-hour timeframe):

  • Notation of anesthesia risk according to established standards of practice (e.g., ASA classification of risk);
  • Identification of potential anesthesia problems, particularly those suggesting potential complications or contraindications to the planned procedure (e.g., difficult airway, ongoing infection, limited intravascular access);
  • Additional pre-anesthesia data as needed or required, per the type of anesthesia to be administered (e.g., stress tests, additional specialist consultation); and
  • Development of the plan for the patient’s anesthesia care, including the type of medications for induction, maintenance, and post-operative care and discussion with the patient (or patient’s representative) about the risks and benefits of anesthesia delivery.

Documentation: Intra-operative 
Intra-operative/procedural anesthesia is a time-based component of the service, and must be documented to the minute for every patient who receives general or regional anesthesia or MAC. The documentation should identify that the anesthesia provider performed a review immediately before initiation of an anesthetic procedure, including a check of NPO (nil per os, or “nothing in the mouth”) status and of the equipment, drugs, and gas supply. A patient taken into surgery/anesthetized less than eight hours after they have last eaten should only be done in emergent cases, such as for an appendectomy.
Documentation, albeit a challenge because the provider must have his or her hands on the patient at the same time, must include:

  • Time-based documentation of monitoring the patient’s vitals and use of monitor(s)
  • The doses of drugs and agents used (propofol, etomidate, opioids, ketamine, isoflurane, etc.)
  • The times and routes of administration (IV, IM, inhalation, pre-oxygen, and any adverse reactions
  • The types and amounts of IV fluids used, including blood and blood products (and times of administration)
  • The techniques used and the patient positions (supine, prone, jackknife)
  • IV lines (arterial line, central venous catheter, IV site, and size)
  • Airway devices (LMA, oral or nasal airway, mask)
  • Technique for insertion and location (intubation/endotracheal)
  • Unusual events during the administration of anesthesia
  • The status of the patient at the conclusion of anesthesia (vitals, stable, dentition intact)

Documentation: Post-op 
A post-anesthesia evaluation must be completed and documented no later than 48 hours after the procedure requiring anesthesia services. The evaluation is required any time general, regional, or monitored anesthesia has been administered to the patient. The 48-hour timeframe begins the moment the patient is moved into the recovery area (post anesthesia care unit or PACU).
As a rule, the evaluation should not be performed until the patient is sufficiently recovered from the acute phase of the anesthesia, so he or she may participate in the evaluation (respond and answer questions appropriately, follow directions for simple tasks, etc.). Best practice is for the evaluation to take place in the PACU/intensive care unit (ICU) or specified recovery area in the facility. When necessary, it’s acceptable for the post-anesthesia evaluation to be completed after the patient is moved to another inpatient location or, for same-day surgeries, after the patient is discharged (if state law and hospital policy permits), as long as it is completed within 48 hours.
There are times when the patient is unable to participate in the post-anesthesia evaluation due to extenuating circumstances, such as post-operative sedation, mechanical ventilation, etc. In such a case, the post-anesthesia evaluation should be completed and documented within 48 hours with notation that the patient was unable to participate. This documentation should include the reason for the patient’s inability to participate, as well as expectations for recovery time, if applicable.
The elements of an appropriately documented post-anesthesia evaluation should include, at minimum:

  • Respiratory function, including respiratory rate, airway patency, and oxygen saturation
  • Cardiovascular function, including pulse rate and blood pressure
  • Mental status
  • Temperature
  • Pain
  • Nausea and vomiting
  • Post-operative hydration

Depending on the specific surgery or procedure performed, additional types of monitoring and assessment may be necessary.
Documentation requirements for anesthesia come from various authorities. It’s important that you observe any rules specific to your state laws, as well as the hospital’s governing body.
A Final Documentation Requirement
The Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery™ is a Joint Commission standard that requires a “time-out” to be performed by both the surgeon and the anesthesia provider. The procedure is not started until all questions or concerns are resolved. The time out is performed immediately before starting an invasive procedure or making the incision.
A designated member of the teams starts the standardized time out and involves the immediate members of the procedure team, which consists of: the individual performing the procedure, anesthesia providers, circulating nurse, operating room technician, and other active participants who will be participating in the procedure from the beginning. All relevant members of the team actively communicate during the time out, in which the members agree, at a minimum, on the following: correct patient identity, correct site, and the procedure to be done. In the event the same patient has two or more procedures, another surgical time out must be performed before starting each procedure. The amount and type of documentation is determined by the organization to support the completed time out.
Michelle N. Myrick, CPC, CPC-I, an anesthesia education documentation specialist at Sheridan Healthcorp in Sunrise, Fla., has more than 25 years experience in the fields of medical billing, coding, and compliance. She is the founder of and served as executive co-chair for the Coding on the River physician medical coding conference held in Jacksonville, Fla., 2004-2012. Myrick has served the Jacksonville River City Chapter as an officer for eight years, four of which were in the role of president-elect and president.

Selected References
ASA, “Distinguishing Moderate Anesthesia from Moderate Sedation/Analgesia.” www.asahq.org, 2004
ASA Task Force, “Practice Guidelines for Sedation and Analgesia by Non-anesthesiologists,” Anesthesiology, 2002; 96: 1004
ASA: “Position on Monitored Anesthesia Care,” www.asahq.org, 2005
“Clarification of the Interpretive Guidelines for the Anesthesia Services Condition of Participation,” May 21, 2010; Transmittal 59 (R59SOMA) and Revised Appendix A, Interpretive Guidelines for Hospitals
Sherwood, E.R., Williams, C.G., Prough, D.S., “Anesthesiology Principles, Pain Management, and Conscious Sedation,” Textbook of Surgery, 18th edition, Philadelphia, Pa., Saunders Elsevier
Hawkins J.L., Arens, J.F., Bucklin, B.A., et al. “Practice Guidelines for Obstetric Anesthesia: An Updated Report by the American,” 2008: Chapter 18.
ASA Task Force on Obstetric Anesthesia, “Anesthesiology,” April 2007; 106(4)

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Renee Dustman, BS, AAPC MACRA Proficient, is managing editor - content & editorial at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. Renee has more than 30 years' experience in journalistic reporting, print production, graphic design, and content management. Follow her on Twitter @dustman_aapc.

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